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It is generally understood that toe walking involves the absence or limitation of heel strike in the contact phase of the gait cycle. Toe walking has been identified as a symptom of disease processes, trauma and/or neurogenic influences. When there is no obvious cause of the gait pattern, a diagnosis of idiopathic toe walking (ITW) is made. Althoug...
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... literature relating to ITW and sensory processing was reviewed according to the guidelines for evidence review set out by the National Health and Medical Research Council (NHMRC) [72]. These guidelines set out the process of evaluating the relationship of a medi- cal condition's aetiology and risk factors (Table 3). This relationship can only be explored when there has been a clear association between the factor and disease. ...
Citations
... Several etiological hypotheses have gained visibility, such as the theory of sensory processing dysfunction (SPD), with studies suggesting a possible association with vestibular dysfunctions (12) . Additionally, genetic etiology has been considered, with the potential of an autosomal dominant variable expression characteristic (13) . ...
... Furthermore, some studies have proposed an association of ITW with SPD (12,23) . It is known that patients diagnosed with ASD might have a higher prevalence of ITW-up to 20.1%-with a high rate of tight heel cords (12%) (24,25) . ...
Objective: Consolidate the current knowledge on idiopathic toe walking, provide a critical overview, and identify areas for potential future research. Methods: An electronic search was conducted in the following databases up to June 2023: MEDLINE, EBSCO, Embase, CINAHL Plus, and PubMed. The PICO framework was employed to define search terms. Results: Despite considerable methodological heterogeneity among studies, a stronger inclination was found to investigate etiological and prognostic factors. There is a trend for a higher prevalence in boys with a positive family history. Novel classifications have been proposed to improve differential diagnosis. Among conservative treatment options, there is stronger evidence for gait improvement using serial casting followed by orthoses. Severe cases may benefit from surgical zone III gastrocsoleus lengthening. Conclusion: Further studies with standardized methodologies are required to clarify questions about this condition's etiology, classification, and treatment. Nonetheless, there is a higher level of evidence supporting conservative treatments with serial casting and orthoses and zone III gastrocsoleus lengthening for severe cases in the second decade of life. Level of evidence II; Diagnostic studies.
... It affects 7% to 24% of children, or about 1 in 100 new patients at orthopaedic and paediatric clinics 6,7 . The causes of ITW include sensorimotor disorders and the incorrect development of sensory processes [8][9][10] . Lateral scoliosis and genetic factors, which are estimated to account for 10% to 80% of all ITW cases, predispose individuals to this type of gait 7,9,11 . ...
... The causes of ITW include sensorimotor disorders and the incorrect development of sensory processes [8][9][10] . Lateral scoliosis and genetic factors, which are estimated to account for 10% to 80% of all ITW cases, predispose individuals to this type of gait 7,9,11 . Despite lacking clearly de-fined causes of ITW, it involves numerous symptoms, e.g. ...
... The diagnosis of ITW requires simultaneously analysing the functioning of the skeletal, muscular and nervous systems. Diagnosis consists of taking a patient's medical history and making various assessments (visual, measurement, activity and functional evaluation) 2,9,12,13 . Activi-ty assessment of musculoskeletal disorders is based on an analysis of the activity and activation of the lower limb muscles during walking by means of EMG and the assessment of shin muscle strength 11,14,15 . ...
Introduction: Analyses related to idiopathic toe walking (ITW) are limited to the functioning of the lower-limb. It is recommended to broaden our understanding and consider other parts of the body in accordance with the principles of tensegrity.
... 9 However, some children continue toe-walking in the absence of any known medical condition and they can walk with a heel-toe gait on request. 10 Idiopathic toe walking (ITW) is considered a diagnosis of exclusion 11 and defined as the persistence of toe-walking after 3 years of age, in the absence of any known neurologic, musculoskeletal, or psychological disorder. 12 The reason for its origin or persistence remains unknown, 11 but it has been proven that a family history of toe-walking enhances predisposition to ITW. 13 The diagnosis, appearance, prevalence, and treatment of toe-walking continues to be widely discussed in the literature. ...
... 10 Idiopathic toe walking (ITW) is considered a diagnosis of exclusion 11 and defined as the persistence of toe-walking after 3 years of age, in the absence of any known neurologic, musculoskeletal, or psychological disorder. 12 The reason for its origin or persistence remains unknown, 11 but it has been proven that a family history of toe-walking enhances predisposition to ITW. 13 The diagnosis, appearance, prevalence, and treatment of toe-walking continues to be widely discussed in the literature. 11 A study carried out in Sweden 14 found a prevalence for toe-walking of 4.9% in healthy children at the age of 5.5 years and diminishes with age. ...
... 12 The reason for its origin or persistence remains unknown, 11 but it has been proven that a family history of toe-walking enhances predisposition to ITW. 13 The diagnosis, appearance, prevalence, and treatment of toe-walking continues to be widely discussed in the literature. 11 A study carried out in Sweden 14 found a prevalence for toe-walking of 4.9% in healthy children at the age of 5.5 years and diminishes with age. However, a prevalence for toewalking of 41% was found in children with neuropsychiatric diagnosis or developmental delays. ...
Background: The Toe Walking Tool (TWT) was developed in Australia as a valid and reliable screening tool for children who toe-walk. However, psychometric properties of the Spanish version of the TWT have not been studied. The aim of this study was to assess psychometric properties and clinical usefulness of the Spanish version of the TWT.
Methods: A cross-sectional study was conducted. Twelve children were assessed with the TWT. Intrarater and interrater reliability and agreement were calculated using the intraclass correlation coefficient (ICC) and the Fleiss kappa method for multiple raters. Internal consistency and construct validity were assessed with the Kuder-Richardson formula 20 coefficient and known-group methods, respectively. Sensitivity and specificity were analyzed using the receiver operating characteristic curve. The Content Validity Index was calculated to determine clinical usefulness.
Results: An excellent intrarater (ICC = 1) and interrater reliability (ICC = 0.8), moderate interrater agreement (Fleiss kappa, 0.6), strong internal consistency (Kuder-Richardson formula 20 coefficient, 0.86), and very good construct validity were found. Sensitivity and specificity results were appropriate (area under the curve, 0.845). The Content Validity Index was 0.906, suggesting high usefulness.
Conclusions: The Spanish version of the TWT was found to be a valid, reliable and useful screening tool for children who toe-walk, providing evidence for its recommendation.
... Some research studies have highlighted the presence of altered sensory processing, encompassing tactile, proprioceptive, vestibular, and visual processing, in several children affected by ITW. Furthermore, several initiatives were implemented to confirm the disruption of sensorimotor regulation [24][25][26][27][28][29][30][31]. ...
Idiopathic toe walking (ITW) occurs in about 5% of children. Orthopedic treatment of ITW is complicated by the lack of a known etiology. Only half of the conservative and surgical methods of treatment give a stable positive result of normalizing gait. Available data indicate that the disease is heterogeneous and multifactorial. Recently, some children with ITW have been found to have genetic variants of mutations that can lead to the development of toe walking. At the same time, some children show sensorimotor impairment, but these studies are very limited. Sensorimotor dysfunction could potentially arise from an imbalanced production of neurotransmitters that play a crucial role in motor control. Using the data obtained in the studies of several pathologies manifested by the association of sensory–motor dysfunction and intestinal dysbiosis, we attempt to substantiate the notion that malfunction of neurotransmitter production is caused by the imbalance of gut microbiota metabolites as a result of dysbiosis. This review delves into the exciting possibility of a connection between variations in the microbiome and ITW. The purpose of this review is to establish a strong theoretical foundation and highlight the benefits of further exploring the possible connection between alterations in the microbiome and TW for further studies of ITW etiology.
... 2 Their diagnosis referred to otherwise healthy children who were displaying a toe walking gait in the absence of a known neurological or orthopaedic cause. Since then, various causal hypotheses and possible contributing factors have been put forward, such as a possible underlying disorder of the sensory nervous system, 3,4 problems with isolated aspects of motor development, 5 or the excessive use of so-called "baby walkers." 6 Finally, ITW has also been described as "habitual toe walking," which suggests a voluntary choice of walking pattern by the patient as the cause of the condition. ...
Idiopathic toe walking (ITW) describes a condition affecting approximately 4.5% of children. Toe walking is an accompanying symptom for many hereditary disorders. This retrospective study uses next-generation sequencing-panel-diagnosis to investigate the feasibility of genetic testing to research the possible genetic causes of ITW and for differential diagnosis.
Data were taken from our inhouse database, the minimum age for participants was 3 years. Underlying neurological or orthopaedic conditions were tested for and ruled out prior to diagnosing ITW. Patients, who experienced complications before, during or immediately after birth, children with autism, and patients toe walking less than 50% of the time were excluded.
Eighty-nine patients were included in the study, in which 66 (74.2%) patients were boys and 23 (25.8%) girls. Mean age at testing was 7.7 years (range: 3–17 years). Fifteen of the 89 patients included in the study (16.9%) had a genetic variant identified as likely pathogenic or pathogenic by the genetics laboratory. Additionally, we found 129 variants of uncertain significance. About 65.2% of patients showed a pes cavus foot deformity, 27% of patients reportedly had at least one relative who also displayed the gait anomaly, and 37.1% had problems with their speech development.
Despite the limitations of the sample size and the scope of our genetic testing targets, our results indicate that research into the genetic causes of ITW could better our understanding of the causes of ITW in otherwise healthy children, to help develop novel methods to detect serious conditions early. ITW could be an early onset symptom for further hereditary conditions.
... Ураження мозку проявляється порушенням м'язового тонусу та координації рухів, що проявляється нездатністю пацієнта зберігати нормальну позу та виконувати довільні рухи [7,8]. Причиною цього є не лише спастичні паралічі та парези, а й множинні контрактури, що призводять до формування деформацій кісткових сегментів кінцівок, які прогресують в процесі зростання та розвитку дитини [12,9,10]. ...
The purpose of this work is to assess the effectiveness of the rehabilitation of children with central nervous system disabilities when applying the reflex-loading device "Gravistat". Material and methods. The method of assessing the effectiveness of rehabilitation measures was carried out before and after a 10-day rehabilitation course according to the generally accepted GMFM scale (Gross Motor Function Measurement Score Sheet). 280 children aged from 4 to 18 years who had impaired functions of the musculoskeletal system due to central nervous system disabilities were examined and then divided into 2 groups: the main test group involved 200 children with disabilities, whose comprehensive rehabilitation program included the device "Gravistat"; the control group included 80 children with disabilities who did not receive the treatment using the "Gravistat" device. Results. The analysis of the received data of the comparative indicators of both groups before the recovery course showed the absence of a reliable difference in all parameters that were measured. (p>0.05). Comparison of the indicators of the rehabilitation program effectiveness for children of both groups showed a significant increase in indicators after the completion of the rehabilitation course in all measured parameters in children with disabilities of the main group (when using reflex-loading devices) compared to similar indicators in children of the control group. Thus, the indicator "A-Lying and turning" in the main group was 8.82±1.10 points, and in the control group - 7.13±0.82 points; "B-Seats" - 9.20±1.24 and 7.33±0.78 points, respectively; "C-Lying, crawling" - 9.56±1.11 and 7.38±0.74 points; "D-Standing" - 9.78±1.08 and 6.56±0.61 points; "E-Walking, running, jumping" - 10.00±1.02 points in the main group and 6.94±0.66 points in the control group (p<0.05). Conclusion. The analysis of data evaluating the effectiveness of the rehabilitation program in the children of the main group, when using the "Gravistat" reflex loading device, has shown a reliable improvement in all parameters of the rehabilitation program in comparison with the indicators in the children of the control group.
... Ураження мозку проявляється порушенням м'язового тонусу та координації рухів, що проявляється нездатністю пацієнта зберігати нормальну позу та виконувати довільні рухи [9,10,11]. Причиною цього є не лише спастичні паралічі та парези, а й множинні контрактури, що призводять до формування деформацій кісткових сегментів кінцівок, які прогресують в процесі зростання та розвитку дитини [12,13,14]. ...
This review article aims at analyzing the modern medical literature on evaluating the effectiveness of current methods of rehabilitation care for children with disabilities and locomotor disabilities. According to the latest reports, in the structure and causes of children disability for 2011-2015, diseases of the nervous system (17.0% -18.9%) rank the second position. Cerebral palsy is a serious disease leading to disability. Current social and economic situation in Ukraine necessitates the strengthening of social protection of children with disabilities, the definition of priority areas in this field of care, and put the early social rehabilitation of children with disabilities among the social and medical priorities. Along with impacted psychophysical development, children can experience social maladaptation, lack of social contacts, low sociometric status that negatively impacts their mental development, the emotional and volitional spheres. Therefore, it is important to introduce wide-scale socio-psychological rehabilitation among this category of children in order to restore lost socio-psychic functions. The main goal of rehabilitation care is to improve the quality of life of patients and to promote their maximum social adaptation. For further development and improvement of the rehabilitation system, various scientific studies are being carried out. One of the important directions in this domain is the evaluation of the effectiveness of rehabilitation measures. The study of methods for evaluating complex rehabilitation programs is a promising direction for the implementation of approaches in organizing an in-depth investigation of this problem. The evaluation of the effectiveness of socio-psychological, psychological-pedagogical, physical rehabilitation care for children with disabilities, cerebral palsy and other central nervous system disorders and locomotive disorders should be carried out by multidisciplinary teams. Despite the significant number of existing methods for assessing the effectiveness of rehabilitation care, there are currently no highly effective and specific methods, and the main disadvantages of existing methods, according to the studied literature sources, are low specificity and laboriousness. Summarizing all of the above, it is important to evaluate the results of literature data in order to identify trends associated with modern methods for assessing rehabilitation measures for children with disabilities.
... TTB can be observed in a spectrum of clinical manifestations, and it can present with different levels of severity both in children with typical development and in children with neurodevelopmental disorders, including ASD [22][23][24]. In some individuals with ASD, TTB can completely disappear over time without any intervention. ...
Atypical sensory processing is frequently reported in persons with autism spectrum
disorders (ASD), and it is one of the described diagnostic criteria for ASD. There is also mounting literature supporting the presence of motor impairments in individuals with ASD. Among these motor signs, tip-toe behavior (TTB) is a possible clinical finding, but its etiology is not clearly understood.
It is suggested that TTB in ASD could be a sign of a sensory modulation impairment, but evidence is lacking and controversial. The main aim of this pilot study is to explore sensory features in a sample (4 females; 28 males) of children and adolescents with ASD (age range: 7–18). All participants also presented Intellectual Disability. Participants were divided in two groups, matched for age and gender, on the basis of the presence or absence of TTB (16 ASD TTB group vs. 16 ASD NO-TTB group) and then evaluated by using the Short Sensory Profile. We found that both ASD groups tend to
significantly present sensory-related behavioral symptoms, but ASD TTB individuals more frequently showed the specific pattern of “under responsive/seeks sensation” than ASD NO-TTB individuals.
These preliminary findings support that sensory-motor features might be taken into consideration when rehabilitation for TTB in children and adolescents with ASD is necessary.
... Numerosas series han encontrado correlación entre la aparición de la MPI como la expresión motora de una disfunción cerebral mínima (5) (8). Algunos estudios han detectado alteraciones relacionadas con el control motor, la visuo-percepción, la integración espacial e incluso el desarrollo del lenguaje (5) (13) sugiriéndose la posibilidad de que bajo el trastorno se encuentre una alteración del procesamiento sensorial (53). Esta línea de investigación ha encontrado alteración de los sistemas que procesan la información sensitiva del propio cuerpo e implican alteraciones en la percepción del entorno orientativas hacia otros mecanismos etiopatogénicos (53), ya que se han encontrado peores resultados no sólo en los test que evalúan el perfil sensorial o la competencia motora, sino también peores umbrales de percepción de vibración, peor resultado en los test de equilibrio monopodal, en las pruebas de Integración Sensorial y en las praxias respecto a los niños con marcha normalizada (54) (55). ...
... Algunos estudios han detectado alteraciones relacionadas con el control motor, la visuo-percepción, la integración espacial e incluso el desarrollo del lenguaje (5) (13) sugiriéndose la posibilidad de que bajo el trastorno se encuentre una alteración del procesamiento sensorial (53). Esta línea de investigación ha encontrado alteración de los sistemas que procesan la información sensitiva del propio cuerpo e implican alteraciones en la percepción del entorno orientativas hacia otros mecanismos etiopatogénicos (53), ya que se han encontrado peores resultados no sólo en los test que evalúan el perfil sensorial o la competencia motora, sino también peores umbrales de percepción de vibración, peor resultado en los test de equilibrio monopodal, en las pruebas de Integración Sensorial y en las praxias respecto a los niños con marcha normalizada (54) (55). Las evaluaciones realizadas por profesionales especializados ya sean neurólogos, terapeutas ocupacionales o fisioterapeutas (5) encontraron que un tercio presentaban retrasos motores finos, 40% retrasos viso-motores y más de la cuarta parte (27%) retrasos motores gruesos, retrasos en el habla y lenguaje y/o en otras áreas. ...
... En aquellos menores con MPI y exploración neurológica normal se puede encontrar asociación con trastornos del lenguaje y neurodesarrollo como se ha descrito anteriormente (5) (53). En los casos con afecciones neuro-psiquiátricas la prevalencia aumenta específicamente en pacientes con trastorno del espectro autista (TEA) observándose incidencia y prevalencia de MPI hasta del 41%, (32). ...
Idiopathic toe walking (ITW) is a gait abnormality featured by voluntary adoption of gait
patterns without heel strike, generally in the absence of shortening of triceps surae. It is
very heterogeneous and several hypotheses concerning its etiopathogenesis exist.
Currently, diagnosis is based on the exclusion of other disorders. Children with ITW
may show other comorbidities and clinical problems that lead to outpatient
consultations with orthopedics or physical medicine.
This work focuses on the improvement of the clinical characterization and the gait
assessment of children with ITW. It also evaluates the efficacy of physiotherapy and the
combination of physical therapy with botulinum toxin (BTx) and the gait changes in
children with ITW after BTx. This dissertation focuses on 4 key objectives:
The first objective was to provide a clinical description of a group of patients with ITW
throughout a pediatric physical therapy consultation.
Patients who were referred due to toe walking during the time of the study, were
systematically evaluated through systematic examination and a screening tool called
"Toe Walking Tool" (TWT). Out of all the patients seen (100), 77 were diagnosed of
ITW. Pain, Achilles shortening measured by Silfverskjoldt's maneuver and symptoms of
attention deficit disorder with or without hyperactivity were assessed. Around 4 out of
10 evaluated patients, showed subacute-chronic pain with a significant impact on their
daily life. We also observed that Achilles' shortening was greater in older patients. Knee
flexor shortenings were also found. ADHD diagnosis was frequent comorbidity in this
sample.
The second objective consisted of creating an algorithm for clinical management, the
definition of a standardized protocol for physiotherapy, and the clinical evaluation of the
results after their implementation. As a result, a therapeutic algorithm adapted to our
clinical environment was developed and presented as part of this dissertation. Besides,
in 77 patients, we saw an improvement in pain, muscular shortening, and motor
coordination and a tendency to decrease the frequency of falls.
The third objective, was to evaluate gait in children with ITW through instrumental gait
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analysis. For that, 28 patients with ITW were compared with a control group of 33
healthy children. Spatiotemporal and kinematic parameters were assessed. The
distribution of every parameter was represented and differences between groups were
calculated by Cohen's d and its 95% confidence interval was measured. The major
findings were the great variability in the values of individual parameters and the
absence of clear patterns in the hierarchical clustering analysis. Children with ITW walk
with a longer stance phase, higher hip flexion, anterior pelvic tilt, and lower ankle
dorsiflexion in the swing phase. A method based on the combination of distance-time
warping of kinematic curves and multidimensional scaling shows that the kinematic
abnormalities in ITW correspond to a continuous phenotypic spectrum instead of
several patterns that be distinguished within the same entity.
The fourth objective was to evaluate the changes in spatiotemporal and kinematic
parameters in 28 children with ITW after a single session of BTx administration in
triceps surae muscles. Mixed-effect models adjusted by Bayesian techniques detected
improvements in the percentage of stance phase and a modest increase in ankle
dorsiflexion at initial contact and a correction of other parameters reflecting gait
compensations. Changes were also noticed in parameters that are not altered in
patients with ITW, such as those related to knee flexion during stance time which could
reflect the effect of BTx on gastrocnemii activity.
In conclusion, these results support the importance of improved access to evaluation
and management tools of ITW in our current clinical setting. Protocols, diagnostic aids
such as TWT, prognosis markers and therapies, will allow efficient management of
pain, impaired range of movement, gait and balance problems. Long-term effects of
these therapies or response variability are still uncertain.
On the other hand, instrument gait analysis has shown to be useful in ITW research,
and will hopefully provide quality information which will lead to simplified technologies
and improved access to patients who suffer this illness
... The causes of ITW are unclear. Many clinicians and researchers have suggested a link between ITW and sensory processing dysfunction, but, to date, there is limited research examining this relationship (Ganley and Behnke, 2016;Williams, Tinley, and Curtin, 2010;Williams, Tinley, Curtin, and Nielsen, 2012). One underexplored area is the relationship of sensory processing to ITW. ...
Idiopathic toe-walking (ITW) refers to persistent walking without heel contact for unknown reasons. An underexplored area is the relationship of sensory processing to ITW. This study presents methods to assess sensory differences in individuals with ITW and summarizes results from a pilot testing of the measures. This pilot study included nine children and one young adult with ITW. Ten age-matched controls were recruited to provide a comparison group when norms were not available in the literature. The measures included in this study were as follows: sensory questionnaires; electrodermal activity response to sensory stimuli; monofilaments; biothesiometer; gait on different surfaces; NeuroCom® SMART Balance Master® Sensory Organization Test and Adaptation Test; and ankle position matching. All study procedures were completed in about 3 hours. Children as young as 4 years were able to complete the measures. We observed overall differences in sensory processing, specifically, higher Sensory Processing Measure scores (p = .011), higher resting electrodermal activity (p = .012), increases in heel-toe walking on novel surfaces (p = .034), and more falls with balance perturbation (p = .007) in individuals with ITW. A subset of individuals also showed tactile hyposensitivity (5 out of 10 in the ITW group) and poor equilibrium scores in the Sensory Organization Test (4 out of 9 in the ITW group, 1 unable to complete the test). Our results confirmed the heterogeneity in the etiology of ITW. We propose that further testing in sensory modulation, tactile processing, and vestibular processing is needed to fully explore the impact of sensory processing on children with ITW.
